Incident Investigation Checklist
Employee
Are there any written procedures for the task to be accomplished?
Yes
No
Outdated
Other
Was the employee provided with training or informed about the procedure?
Yes
No
Is the employee physically and mentally capable of carrying out the tasks?
Yes
No
Was the employee provided with the personal protective equipment (PPE) and was he/she correctly wearing them?
Yes
No
Was enough time provided for the employee to accomplish their tasks?
Yes
No
Equipment
Was there any equipment involved in the incident?
Tractor
Trailer
Liftgate
Pallet jack
Hand truck
Other
How did the equipment contribute to the incident?
Through a failure
Lack of feature
Lack of maintenance
Other
Environment
Which of the following environmental factors has contributed to the incident?
Light
Dark
Wet
Heat
Cold weather
Ice
Uneven ground
Visibility
Wind
Other
Management
Is the role of management clearly defined and assigned in hazard recognition and corrective action?
Yes
No
Is management trained in hazard recognition?
Yes
No
Was management aware of a potential deviation that might occur from safety procedures?
Yes
No
Please explain the main cause of the incident and what measures could have been taken to prevent it?
Next Steps
Please assign a task for each key issue in order to prevent further incident
Rows
Task
Task Owner
Due Date
Status
Repair/Replacement of Equipment
1
Environmental Solutions
2
Employee Training
3
Management Training
4
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: